NEW YORK EXPANDS COVERAGE FOR AUTISM

INSIGHTS
On November 1, 2011 Governor Andrew Cuomo signed legislation that will require insurance carriers to offer coverage for the diagnosis and treatment of autism spectrum disorder.  New York becomes the twenty-ninth state to require health insurance coverage for conditions relating to autism spectrum disorder.

IMPLICATIONS
The law becomes effective on November 1, 2012, one year after its enactment, and applies to New York fully insured plans issued or renewed after the effective date.  All fully insured plans subject to the mandate will be required to provide autism coverage as outlined in the legislation.  Self-funded plans are not required to comply.

A similar measure was vetoed last year by former Governor David Paterson as too expensive.  The current bill places an annual $45,000 limit on coverage for “applied behavior analysis” (see below).  Insurance premiums would increase approximately one half of one percent according to legislative estimates.  However, others suggest costs will have to increase more than official estimates to cover this autism mandate. 

What The Law Requires
The law requires that every group plan that provides medical services must now include coverage for the screening, diagnosis, and treatment of autism spectrum disorder.  The law defines autism spectrum disorder as “ any pervasive developmental disorder as defined in the most recent edition of the diagnostic and statistical manual of mental disorders, including autistic disorder, Asperger’s disorder, Rett’s disorder, childhood disintegrative disorder, or pervasive developmental disorder not otherwise specified”. 

The coverage may be subject to annual deductibles, copayments and coinsurance and must be consistent with the cost sharing provisions for other medical conditions.  The coverage may not apply any limits on visits that are solely applied to the treatment of autism spectrum disorder; however coverage for applied behavior analysis may be subject to an annual maximum (adjusted for inflation) of $45,000.  Applied behavior analysis means “the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior”. 

Coverage for treatment includes the following when prescribed or ordered by a licensed physician or psychologist:

• Behavioral health treatment such as counseling and treatment programs.
• Psychiatric and psychological care including direct or consultative services by a licensed psychiatrist or psychologist.
• Medical care provided by a licensed health care provider.
• Therapeutic care provided by social workers, speech, physical and occupational therapists.
• Pharmacy care if the plan covers prescription drugs.

Coverage may be subject to utilization review and external appeals as well as case management and other managed care provisions.  Furthermore, no insurer may terminate coverage or refuse to deliver, execute, issue, amend, adjust or renew coverage to an individual because that individual has been diagnosed with autism spectrum disorder.

ADDITIONAL INFORMATION
For specific questions concerning information contained in this INSIGHTS & IMPLICATIONS, please contact your Chernoff Diamond consultant.

Information contained in this INSIGHTS & IMPLICATIONS is not intended to render tax or legal advice. Employers should consult with qualified legal and/or tax counsel for guidance with respect to matters of law, tax and related regulation.

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